In the Wall Street
Journal on June 17,
2004 in an
article title "Easing the Kidney Shortage" in his column CAPITAL,
David Wessel writes:

Renal Donors Swap
Recipients

If Blood Types Don't
Match;

Cheating on Priority
Lists

June 17,
2004; Page
B1

As of noon yesterday, 58,470
people in the U.S. were waiting for a
kidney transplant. Most won't get one this year. There aren't enough donated
kidneys to go around. Surgeons transplanted just 15,129 kidneys last year. Now a
band of transplant surgeons and economists are trying to fix that by creating a
moneyless market for exchanging kidneys. Most transplanted kidneys come from a
person who has died, a supply that grows slowly because of ignorance about the
need for donations or grieving relatives' reluctance. But a kidney taken from a
live donor works better, and almost everyone has a spare. As techniques improve
for removing healthy kidneys and for suppressing the body's tendency to reject a
transplant, doctors increasingly turn to kidneys from living donors, usually
relatives. Last year, 43% of kidneys transplanted in the U.S. came from living
donors, up from 28% a decade ago. But a biological barrier often blocks a
transplant from a relative. In about a third of all would-be pairs, blood types
are incompatible. In others, the sick person has antibodies that can initiate a
rejection of the donated organ. It's heartbreaking "to have the treasure of the
live donor and then have that not go forward because of a biological obstacle,"
says Massachusetts
GeneralHospital transplant surgeon
Francis DelMonico.

Occasionally, transplant
centers spot a way out: One New England father with blood type A couldn't donate
a kidney to his daughter with blood type B. So he gave a kidney to a teenager
with blood type A, and the teenager's sister gave a kidney for the man's
daughter. New England's transplant centers
have done six such exchanges. Baltimore's JohnsHopkinsUniversity has done
seven.

In the past year,
Hopkins also has done two
exchanges that involved three transplants each, an undertaking that requires six
operating rooms and 60 medical professionals (see diagram2). In New England, Washington, D.C., and elsewhere,
would-be donors unable to give a kidney to a loved one instead have given a
kidney to a stranger. The loved one, in turn, is rewarded by being moved up on
the waiting list for a dead person's kidney.

Such swaps occur,
though, only when the right combination appears or a flurry of e-mails among
transplant centers produces the right mix. A highly organized system alerts
transplant centers when a dead person's kidney is available; there isn't any
system for a man who can't give to, say, his wife, but wants to advertise his
willingness to make a swap. Hopkins transplant surgeon
Robert Montgomery figures that 2,000 or more people could get transplants each
year if there were a national database of such donors.

Transplants are
expensive: Johns Hopkins says the cost is
roughly $120,000 when everything is included. Medicare usually foots the bill
for patients without private insurance, though it doesn't pay that much. Buying
or selling a kidney in the U.S. is illegal.

Donors, recipients and
relatives involved in three-way kidney transplant at JohnsHopkinsHospital in Baltimore last year

Lawyers and ethicists,
after substantial deliberation, decided a few years ago that kidney swaps like
those done in Boston and Baltimore are acceptable. And
doctors agree on some simple rules: The donor must travel to the hospital where
the recipient is; participants may keep identities private if they choose; all
operations in a swap begin simultaneously to avoid anyone backing out halfway
through the swap.

While the doctors were
working all this out, Harvard economist Alvin Roth, a specialist in designing
moneyless markets like the one that matches medical residents to teaching
hospitals, was pondering the problem. He proposed to a visiting protégé, Utku
Ünver of Istanbul's KocUniversity, that the two teach a
course using kidneys as an example. Thinking about kidney donors and recipients,
it turned out, was similar to thinking about the way colleges allocate dorm
rooms, a problem Mr. Ünver and colleagues had studied.

The result was an
article published in the Quarterly Journal of Economics last month by the two
men and a colleague from Koc, Tayfun Sönmez, that describes how to structure a
kidney exchange to identify potential swaps among a large pool of people with
rules that make it very hard for anyone to cheat.

Cheating is an issue in
transplants. In Chicago, for instance, cardiac
doctors have been accused by local prosecutors of overstating the severity of
patients' illnesses to move them up on the priority list for hearts. And rules,
such as those that depend on how long one has been waiting for an organ, don't
always anticipate human cleverness; rules had to be changed, for instance, when
doctors began to put babies on waiting lists for heart transplants before they
were born.

The economists' premise
is simple: Don't expect anyone to do anything that isn't in his or her
self-interest. As long as a computer can identify the one kidney in the pool
that best suits a patient, the system is foolproof, the economists
say.

Massachusetts General's
Dr. DelMonico admits to some skepticism when the economists approached him last
fall. But the collaboration has blossomed over the past few months. Dr.
DelMonico handles the intricacies of forging a consensus among the 14 transplant
centers in New England and finding money to
support a computerized system to implement the economists' design.

Harvard tissue-typing
specialist Susan Saidman, meanwhile, is working to perfect a computer system to
simplify the process of checking to be sure potential recipients don't have
antibodies that could cause them to reject an otherwise suitable donor's
kidney.

The most compelling
moment so far came when Dr. Saidman gave the economists details on 45 pairs in
which the would-be donor was unable to give a kidney to the intended recipient.
Even though each of the 45 had a donor willing to spare a kidney, all were stuck
waiting for the right person to die. With swaps involving two kidneys, the
economists found, eight transplants were possible. If swaps involving three
kidneys were possible, then 11 transplants were possible.